One of my patients was taken ill on holiday and was admitted to the local hospital. The treatment he received couldn't be faulted, especially the nursing. A member of staff was always available; and every few minutes someone would be in his bay attending to a patient, cleaning up spills or just being there.

Then he was moved home for follow-up. Nursing in the second hospital was as bad as the first one had been good. The staff were overloaded: cleaning was perfunctory; and calls for attention by patients could easily be left unanswered for half an hour. It was an all-round shambles.

So why the difference? What is it about these two NHS hospitals which means that one is superb, the other almost criminally negligent?

The answer may lie in my second event. Two years ago one of my college friends acquired a new practice manager. Coming from a non-NHS background, she hit the practice like a tornado. Previous practice managers of his acquaintance had 'done the managerial thing', creating all sorts of protocols, spreadsheets and databases. But his new practice manager never collected data for its own sake, or to look good at the PCT. Instead she used these devices intensively (plus many of her own devising) to identify problems and then make changes, transforming the practice - already well organised - into a unit that was even better.

What is the common link? It's about seeing the wood for the trees. High-quality practitioners (both nursing and managerial) carry out procedures because they lead to clearly identifiable goals. Their actions aren't performed simply to tick boxes or look impressive in the eyes of others. High levels of staffing and thorough ward cleanliness are a response to the needs of incapacitated patients. The practice manager's data and spreadsheets were introduced purely to identify inefficiencies in the practice: they were intended for her personal use only - a means to an end, not to display her or her practice's prowess to others.

Excellence isn't about instigating processes but about achieving goals. In medicine, the end is what counts, not the means.